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The prevalence of a high level of strain was According to Mokken analysis, CSI represented a unidimensional construct of caregiver burden although two of the total 13 items 1 and 13 could not be assigned to any factor by an automatic item selection procedure. The CSI score showed a good discriminative validity between the levels of disability of the care recipient.

Conclusion: The CSI questionnaire shows appropriate psychometric characteristics being a useful instrument to assess different aspects of burden in MS caregivers in clinical practice. Keywords: caregivers, multiple sclerosis, psychometrics, caregiver burden, strain. Multiple sclerosis MS is one of the most common causes of neurological disability in young adults and its prevalence is increasing throughout Europe. Understanding caregiver burden may be crucial for carrying out specific intervention strategies to reduce burden and improve caregiver health.

The CSI has shown high internal consistency, validity, and unidimensional structure and is one of the most frequently used questionnaires to measure caregiver burden.

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Our aim in this study was to assess the dimensional structure and construct validity of the CSI in the management of MS. We performed a post hoc analysis using data from the aforementioned study in order to assess the psychometric performance of the CSI. Written informed consent was obtained from all subjects. This study was conducted in accordance with the provisions of the International Conference on Harmonization Guidelines for Good Clinical Practice and the Declaration of Helsinki.

On clinical appointment, accompanying caregivers completed the CSI questionnaire.


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A total score of 7 or higher indicates a high level of caregiver burden. For continuous data, descriptive statistics were expressed as mean and SD, or median and interquartile range IQR.


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For categorical data, descriptive statistics were expressed as frequencies and percentages. Mokken suggested the following thresholds for interpreting scalability coefficients: weak scale 0. Values of item location below 0 represent easy items; values around 0 represent average difficulty; and values above 0 represent more difficult items. Ideally, a questionnaire should have items covering the full range of difficulty, to ensure complete assessment of the latent dimension it is supposed to measure.

The fit of the RM was assessed by the infit and outfit mean-square statistics and the Andersen likelihood ratio LR test. The infit and outfit mean-square statistics assess item and person fit.

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The infit and outfit mean-square values provide some evidence of construct validity. The Andersen LR test evaluates the gain in likelihood based on separate estimation of item parameters in score groups, against single estimates based on the total sample. The person-item map displays the location difficulty of item parameters as well as the distribution of person parameters along the latent dimension on the same logit scale.

These are useful to compare the range and position of the item measure distribution to the range and position of the person measure distribution. Items should ideally be located along the whole scale to meaningfully measure the ability of all persons. We used the raw and standardized mean difference SMD as effect sizes, and the value for the area under the curve AUC from a receiver operating characteristic analysis.

We considered SMDs of 0. A value of 0.


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  7. We performed the statistical analyses with the program R v3. A total of 72 caregivers from a sample of pwMS were studied. The mean total CSI score was 3. Table 1 shows the demographic and clinical characteristics of the pwMS. Automated item selection procedures suggest most items represented by a single underlying trait of caregiver burden. These items also had the lowest values for item-test correlation. Most items had scalability indices over 0.

    The scalability for the overall scale was 0. This value increased to 0. Table 2 shows the endorsement frequencies and Mokken scalability coefficients. Table 2 provides a summary of the location and fit of each item and Figure 2 shows the item-person map. Figure 2 is a combined graph that shows in its lower part the location of item parameters difficulty along the latent dimension, as well as the distribution of person parameters ability or attainment level along the latent dimension upper part of the graph. Most items cluster along mean difficulty, with three easy items 2, 10, and 12 and one difficult item 7.

    Patients tend to cluster at the mean and lower end of the scale, indicating that most caregivers in this sample would endorse the corresponding items. Figure 2 also shows that some items have the same location scores 8 and 11, 13 and 15, 1 and 4, and 6, 9 and These items do not add scale information and, in principle, they could be either reworded or removed from the scale. The overall CSI score showed a good discriminative validity between the levels of disability of the care recipient.

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